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SAN JOAQUIN LOCAL 11EALTH DISTRICT <br /> FOR OFFICE USE: 16( E. Hazelton Ave. , Stockton, Ca v. <br /> *" Telephone: (209) 466-6731 's'�' <br /> APPLICA ON FOR WELL CONSTRUCTION OR PUMP PER74 <br /> MIT Permit No.• ----O W <br /> THIS bTRMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to Ore San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and thi" ules and Regulations of the San Joaquin Local Health District. <br /> f CENSUS TRACT <br /> JOB ADDRESS/LOCATION �,g C. �'-,mss,:'-- : �_,. <br /> Owner's Name gr . Phone -z/© .� <br /> Address <br /> Contractor's Name ��C /-'� '/�, '� �, License #00079,V Phone �? <br /> TYPE OF WORK (Check) : NEW WELL P-e DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION � PUMP REPAIR J / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> N, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing .•;. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor _ r c <br /> Type of Pump9'.„f.*.��' . =a' � , H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP kT-of the well and notify them before putting the well in use. The above <br /> informatio pe to the-best -of my knowledge and belief. <br /> SIGNED ;a' ,.t t`t '.: <br /> . a r TITLE . (e <br /> .' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE d <br /> ADDITIONAL COMMENTS: <br /> PHASE I4 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /o i 7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />